A 58-year-old man is admitted to the ICU with pneumonia and sepsis. His medical history is notable for coronary artery disease and COPD. He is intubated and receiving a norepinephrine infusion to support blood pressure. On his serum, glucose has ranged from 191 to 283 mg/dL over the last 12 hours.
What is the most appropriate treatment at this time for his blood glucose?
A. No treatment is necessaryCorrect Answer: D
This patient is critically ill with sustained hyperglycemia, blood glucose >180 mg/dL. Sustained hyperglycemia has been associated with increased morbidity and mortality across various patient population. Thus, although hyperglycemia should be avoided, there may additional morbidity associated with hypoglycemia resulting from targeting lower blood glucose levels. Although single center studies showed an apparent benefit to such “intensive insulin therapy,” large randomized multicenter trials have shown the opposite—that intensive insulin therapy (blood glucose 81- 108 mg/dL) is associated with a higher morbidity and mortality than a conventional regimen (blood glucose <180 mg/dL).
Given the repeated blood glucose measurements >180 mg/dL, this patient should be started on insulin therapy. As explained above there is no role for a lower target of 150 mg/dL instead of 180 mg/dL as attempts at tighter control are associated with worse outcomes. Administering long acting insulin to a critically ill patient with blood glucose variability may increase the risk of hypoglycemia. Starting sliding scale insulin that can be adjusted to the specific glucose level is an appropriate starting point for this patient.
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